Veterans Health Administration (VHA) patients are at a significantly elevated risk for fatal and non-fatal suicide attempts and identifying strategies to reduce the risk of suicidal behavior among members of the military and Veterans is a high national priority. The VHA has invested extensively in suicide prevention and, as part of these efforts; the Veterans Crisis Line was developed as an important resource for Veterans and their families. Utilization of the Veterans Crisis Line has expanded steadily since it first opened and, currently, it receives over 20,000 calls per month. Despite high utilization of the Crisis Line, no data are currently available on whether use of the Veterans Crisis Line reduces an individual's likelihood of a suicide attempt or death and it is not feasible to test the efficacy of the Crisis Line in a randomized controlled tril because it is nationally available to all Veterans and their families. More importantly, the Veterans Crisis Line may not reach those individuals at most acute risk for suicide. Our study team conducted a small survey of Veterans treated for recent suicidal crisis in a VHA inpatient psychiatric unit and found that less than half had ever utilized the Veterans Crisis Line and less than a third had used it within the past year. Consequently, we developed and gathered pilot data on a brief intervention designed to increase utilization of the Veterans Crisis Line among high risk patients, called Crisis Line Facilitation (CLF). This single-session intervention involve a discussion of the patient's perceived barriers of crisis line use during periods of suicidal criss. The CLF session ends with the patient calling the Crisis Line with the therapist in the room as a way for Veterans to practice the logistics of making the call and to have direct experiences that may counter any negative beliefs about Veterans Crisis Line use. The proposed study will recruit 500 participants who are currently treated for a suicidal crisis in VHA inpatient psychiatrc but have not recently used the Veterans Crisis Line. This study will be a randomized controlled trial of the impact of CLF compared to enhanced usual care (EUC) on utilization of the Veterans Crisis Line and other mental health services as well as suicide attempt(s). All participants will b re-assessed at 3-, 6- and 12- months post baseline. Analyses will also examine the extent to which post-baseline Crisis Line use mediates the effect of random assignment to CLF on subsequent suicidal behaviors. Qualitative interviews at the end of the study will help understand barriers and facilitators of future implementation of the CLF intervention. If successful, the proposed study will provide key data on the potential efficacy of a brief intervention to improve the utilization of an existing resource, the Veterans Crisis Line, to reduc suicidal behaviors in VHA patients. Developing a brief and effective approach to encourage use of the Crisis Line has the potential to have a significant and substantial impact on suicide rates within the VHA and could be modified and exported to other populations and settings. CRITIQUE 1 1. Significance. Individuals who use VHA services are at increased risk of suicide. Although the VHA has invested extensively in programs and resources to prevent suicidal behavior, suicide rates among Veterans continue to increase. Reducing suicidal behavior in Veterans is a high priority for our nation and the VHA. One resource - the national Veterans Crisis Line (VCL), is different from other crisis hot lines in that VCL staff has access to Veterans electronic medical records and can coordinate access to care. Although the simplicity and face validity of the proposed intervention may suggest to some there is no need to establish its efficacy, the proposed RCT is an appropriate and crucial next step towards adoption and widespread implementation in the VHA. The intervention is grounded in the Theory of Planned Behavior and is based in part upon a study that used a facilitation intervention for 12-step groups, which found that 12-step meeting utilization mediated the effect of the facilitation intervention on substance-related outcomes. The intervention has been piloted, demonstrating feasibility and acceptability. The proposed research is significant because published trials in the area of suicide prevention are rare. Furthermore, there is little data about the use of crisis lines. The mediational analyss testing the extent to which post-baseline use of the Veterans Crisis Line mediates the effect of CLF on suicidal behaviors is a major strength. 2. Approach (including Feasibility). The methods for the proposed RCT are appropriate and rigorous. Inclusion criteria are not based on specific diagnoses and exclusion criteria are minimal, which will help to increase generalizability. Randomization and allocation concealment plans are good. Large sample is justified by relative rarity of suicidal behaviors; follow-up out to 12-months will increase chance of detection. Integration of the CLF with overall treatment planning is well-described and the delineation between CLF and usual care is clear. The study proposes to use well-known, standardized measures appropriate for the target population. Medical record abstractions will capture VCL use, inpatient psychiatric admissions, outpatient MH utilization, and suicidal thoughts, plans, and attempts. Analytic plan, including strategy for handling missing data, appears appropriate Findings from the newly added qualitative component guided by the PRECIS framework will help to guide future dissemination efforts by assessing barriers and facilitators of the CLF intervention. Sample interview guides provided in appendix are on target. Dissemination plan is strong and will capitalize on the support of and connections with key stakeholders 3. Impact and Innovation. The proposed intervention is innovative. Its simplicity and face validity will help to increase uptake. Strong letters of support from the VA Deputy Director of Suicide Prevention and the Director the Mental Health QUERI endorse the Crisis Line Facilitation intervention to enhance suicide prevention efforts for high risk Veterans, but emphasize that like many novel approaches, it is simply unrealistic to expect the VHA to commit time and resources to implement the intervention without evidence, and that the proposed RCT is needed to establish efficacy prior to implementation. 4. Investigator Qualifications, and Facilities and Resources. The PI is a VA Clinical Psychologist with a faculty appointment at the University of Michigan Medical School with the rank of Associate Professor. Although it appears the wrong biosketch was submitted in this application for the PI, it is clear that the PI is highly productive and well positioned to lead the proposed research, having NIH/VA/DoD-funded research and over 100 peer-reviewed publications in the areas of suicide, chronic pain, substance abuse, and dual diagnosis disorders. Other members of the investigative team have relevant expertise in epidemiology, psychiatry, psychology, and qualitative methods. The facilities and scientific environment are excellent. The proposed research will be supported with resources from the Ann Arbor COIN and SMITRECC, as well as the Canandaigua Center of Excellence. 5. Multiple PI Leadership Plan. (if applicable) N/A 6. Adequacy of Response to Previous Feedback Provided by HSR&D Regarding the Proposed Study. The investigators have been extremely responsive to the prior review. In addition to letters from QUERI and operational stakeholders supporting the need for the proposed efficacy study, the application has provided additional clarification on the proposed meditational analysis, as well as how the Crisis Line Facilitation intervention fits into overall treatment planning and is a supplement to, rather than a substitute for, usual care. The addition of qualitative methods to explore Veterans' reluctance to use the Crisis line and/or lack of prior use, as well as barriers and facilitators to future implementation, has greatly strengthened the application. 7. Protection of Human Subjects from Research Risk. The human subjects plan for Veteran participants is very thorough and provides a very detailed and thoughtful plan to manage acutely suicidal participants. VA staff who will be participating in qualitative interviews, however, do not appear to be acknowledged to be human subjects. 8. Inclusion of Women and Minorities in Research. The study population is anticipated to reflect the racial/ethnic and gender distribution of the study sites, with good representation of African Americans. 9. Budget. A total of $1,308,474 has been requested for the study, which will be conducted over a 4-year period. The applicants have applied for and have received a waiver to increase the budget over the standard limit in order to cover 1.5 FTE additional research assistants. 10. Overall Impression. This revised application addresses an important evidence gap and a topic of critical importance to Veterans and VHA. The project has support from QUERI MH leadership and Suicide Prevention stakeholders who feel that the proposed efficacy trial is a crucial and necessary step prior to widespread implementation. 11. Key Strengths. 1. Novel, innovative intervention that has the potential for widespread dissemination and implementation. 2. Well-designed study with appropriate methods. 3. Collection of qualitative data on barriers and facilitators has the potential to assist in widespread dissemination, as well as provide crucial information even in the event of negative findings. 4. Adequate human subject protections for high-risk Veteran population 12. Key Weaknesses. 1. Potential risk/protections for VA staff who will participate in qualitative interviews is not addressed in human subjects plan